Figures
- Fig. 1.—
Algorithm for pharmacological treatment of chronic obstructive pulmonary disease (COPD). SA-BD: short-acting bronchodilator; LA-BD: long-acting bronchodilator; ICS: inhaled corticosteroid. Assess effectiveness by treatment response criteria. If forced expiratory volume <50% predicted and exacerbations of COPD requiring a course of oral corticosteroid or antibiotic occurred at least once within the last year, consider adding regular ICS. Always ensure the patient can use an inhaled device effectively and understands its purpose. If an ICS and a long-acting β‐agonist are used, prescribe a combination inhaler.
- Fig. 2.—
A flow chart for prescribing long-term oxygen therapy (LTOT). Pa,O2: arterial oxygen tension; Sa,O2: arterial oxygen saturation; ABG: arterial blood gases.
- Fig. 3.—
Algorithm for pre-operative testing for lung resection. DL,CO: carbon dioxide diffusing capacity of the lung; FEV1: forced expiratory volume in one second; ppo: predicted postoperative; V′O2,max: maximum oxygen consumption.
- Fig. 4.—
Schematic algorithm from the National Emphysema Therapy Trial for Lung Volume Reduction Surgery (LVRS) (see text). FEV1: forced expiratory volume in one second; DL,CO: carbon dioxide diffusing capacity of the lung. Modified from 69.
- Fig. 5.—
Algorithm to correct hypoxaemia in an acutely ill chronic obstructive pulmonary disease patient. ABG: arterial blood gas; Pa,O2: arterial oxygen tension; O2: oxygen; Sa,O2: arterial oxygen saturation; Pa,CO2: arterial carbon dioxide tension; NPPV: noninvasive positive pressure ventilation.
- Fig. 6.—
Flow-chart for the use of noninvasive positive pressure ventilation (NPPV) during exacerbation of chronic obstructive pulmonary disease (COPD) complicated by acute respiratory failure. MV: mechanical ventilation; Pa,CO2: arterial carbon dioxide tension.
- Fig. 7.—
Continuum of care for chronic obstructive pulmonary disease (COPD). FEV1: forced expiratory volume in one second.
Tables
- Table 1
Spirometric classification of chronic obstructive pulmonary disease (COPD)
Severity Postbronchodilator FEV1/FVC FEV1 % pred At risk# >0.7 ≥80 Mild COPD ≤0.7 ≥80 Moderate COPD ≤0.7 50–80 Severe COPD ≤0.7 30–50 Very severe COPD ≤0.7 <30 FEV1: forced expiratory volume in one second
FVC: forced vital capacity
#: patients who smoke or have exposure to pollutants, have cough, sputum or dyspnoea
- Table 2
Risk factors for chronic obstructive pulmonary disease
Host factors Exposures Genetic factors Smoking Sex Socio-economic status Airway hyperreactivity, IgE and asthma Occupation Environmental pollution Perinatal events and childhood illness Recurrent bronchopulmonary infections Diet Ig: immunoglobulin
- Table 3
Differential diagnosis of chronic obstructive pulmonary disease (COPD)
Diagnosis Suggestive features COPD Mid-life onset Slowly progressing symptoms Long history of smoking Asthma Early onset Varying symptoms Symptoms during the night/early morning Presence of allergy, rhinitis and/or eczema A family history Airflow limitation that is largely reversible Congestive heart failure Fine basilar crackles on auscultation Dilated heart on chest radiography Pulmonary oedema Volume restriction not airflow limitation on pulmonary function tests Bronchiectasis Large volume of purulent sputum Commonly associated with bacterial infection Coarse crackles/clubbing on auscultation Bronchial dilation and bronchial wall thickening on chest radiography/CT Tuberculosis Onset at all ages Lung infiltrate on chest radiography Microbiological confirmation High local prevalence of tuberculosis Obliterative bronchiolitis Younger onset and in nonsmokers History of rheumatoid arthritis/fume exposure Hypodense areas on expiration on CT suggestive of bronchiolitis Diffuse panbronchiolitis Effects mostly male nonsmokers Almost all have chronic sinusitis Diffuse small centrilobular nodular opacities and hyperinflation on chest radiography and HRCT CT: computed tomography
HRCT: high resolution computed tomography
- Table 4
Key points of the Treating Tobacco Use and Dependence guidelines
Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments Clinicians and healthcare delivery systems must institutionalise the consistent identification, documentation and treatment of every tobacco user at every visit Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment Five first-line pharmacotherapies for tobacco dependence are effective: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray and nicotine patch, and at least one of these medications should be prescribed in the absence of contraindications Tobacco-dependence treatments are cost effective relative to other medical and disease prevention interventions - Table 5
Effect of commonly used medications on important clinical outcomes in chronic obstructive pulmonary disease
FEV1 Lung volume Dyspnoea HRQoL AE Exercise endurance Disease modifier by FEV1 Mortality Side-effects Short-acting β‐agonists Yes (A) Yes (B) Yes (A) NA NA Yes (B) NA NA Some Ipratropium bromide Yes (A) Yes (B) Yes (A) No (B) Yes (B) Yes (B) No NA Some Long-acting β‐agonists Yes (A) Yes (A) Yes (A) Yes (A) Yes (A) Yes (B) No NA Minimal Tiotropium Yes (A) Yes (A) Yes (A) Yes (A) Yes (A) Yes (B) NA NA Minimal Inhaled corticosteroids Yes (A) NA Yes (B) Yes (A) Yes (A) NA No NA Some Theophylline Yes (A) Yes (B) Yes (A) Yes (B) NA Yes (B) NA NA Important FEV1: forced expiratory volume in one second
HRQoL: health-related quality of life
AE: exacerbation of COPD
NA: evidence not available
GOLD grade levels are indicated in brackets (see text for explanation)
- Table 6
Factors associated with favourable or unfavourable outcome in classical bullectomy
Parameter Favourable Unfavourable Clinical Rapid progressive dyspnoea despite maximal medical therapy Older age Ex-smoker Co-morbid illness Cardiac disease Pulmonary hypertension >10% weight loss Frequent respiratory infections Chronic bronchitis Physiological Normal FVC or slightly reduced FEV1 <35% pred FEV1 >40% pred Low trapped gas volume Little reversibility Decreased DL,CO High trapped lung volume Normal or near normal DL,CO Normal Pa,O2 and Pa,CO2 Imaging CXR Bulla >1/3 hemithorax Vanishing lung syndrome Poorly defined bullae CT Large and localised bulla with vascular crowding and normal pulmonary parenchyma around bulla Multiple ill-defined bullae in underlying lung Angiography Vascular crowding with preserved distal vascular branching Vague bullae; disrupted vasculature elsewhere Isotope scan Well-localised matching defect with normal uptake and washout for underlying lung Absence of target zones, poor washout in remaining lung CXR: chest radiography
CT: computed tomography
FVC: forced vital capacity
FEV1: forced expiratory volume in one second
DL,CO: carbon monoxide diffusing capacity of the lung
Pa,O2; arterial oxygen tension
Pa,CO2; arterial carbon dioxide tension
Table modified from 68
- Table 7
Disease-specific guidelines for candidate selection for lung transplantation in chronic obstructive pulmonary disease patients
FEV1 ≤25% pred (without reversibility) and/or Resting room air Pa,CO2 >7.3 kPa (55 mmHg) and/or Elevated Pa,CO2 with progressive deterioration requiring long-term oxygen therapy Elevated pulmonary arterial pressure with progressive deterioration FEV1: forced expiratory volume in one second
Pa,CO2: arterial carbon dioxide tension
- Table 8
Clinical history, physical findings and diagnostic procedures in patients with exacerbation of chronic obstructive pulmonary disease (COPD)
Level I Level II Level III Clinical history Co-morbid conditions# + +++ +++ History of frequent exacerbations + +++ +++ Severity of COPD Mild/moderate Moderate/severe Severe Physical findings Haemodynamic evaluation Stable Stable Stable/unstable Use accessory respiratory muscles, tachypnoea Not present ++ +++ Persistent symptoms after initial therapy No ++ +++ Diagnostic procedures Oxygen saturation Yes Yes Yes Arterial blood gases No Yes Yes Chest radiograph No Yes Yes Blood tests¶ No Yes Yes Serum drug concentrations+ If applicable If applicable If applicable Sputum gram stain and culture No§ Yes Yes Electrocardiogram No Yes Yes +: unlikely to be present
++: likely to be present
+++: very likely to be present
#: the more common co-morbid conditions associated with poor prognosis in exacerbations are congestive heart failure, coronary artery disease, diabetes mellitus, renal and liver failure
¶: blood tests include cell blood count, serum electrolytes, renal and liver function
+: serum drug concentrations, consider if patients are using theophylline, warfarin, carbamezepine, digoxin
§: consider if patient has recently been on antibiotics
- Table 9
Indications for hospitalisation of patients with a COPD exacerbation
The presence of high-risk co-morbid conditions, including pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure Inadequate response of symptoms to outpatient management Marked increase in dyspnoea Inability to eat or sleep due to symptoms Worsening hypoxaemia Worsening hypercapnia Changes in mental status Inability of the patient to care for her/himself (lack of home support) Uncertain diagnosis Inadequate home care - Table 10
Level I: outpatient treatment
Patient education Check inhalation technique Consider use of spacer devices Bronchodilators Short-acting β2‐agonist# and/or ipratropium MDI with spacer or hand-held nebuliser as needed Consider adding long-acting bronchodilator if patient is not using one Corticosteroids (the actual dose may vary) Prednisone 30–40 mg orally·day−1 for 10–14 days Consider using an inhaled corticosteroid Antibiotics May be initiated in patients with altered sputum characteristics+ Choice should be based on local bacterial resistance patterns Amoxicillin/ampicillin¶, cephalosporins Doxycycline Macrolides§ If the patient has failed prior antibiotic therapy consider: Amoxicillin/clavulanate Respiratory fluoroquinolonesƒ MDI: metered-dose inhaler
#: salbutamol (albuterol), terbutaline
+: purulence and/or volume
¶: depending on local prevalence of bacterial β‐lactamases
§: azithromycin, clarithromycin, dirithromycin, roxithromycin
ƒ: gatifloxacin, levofloxacin, moxifloxacin
- Table 11
Level II: treatment for hospitalised patient
Bronchodilators Short-acting β2‐agonist and/or Ipratropium MDI with spacer or hand-held nebuliser as needed Supplemental oxygen (if saturation <90%) Corticosteroids If patient tolerates, prednisone 30–40 mg orally·day−1 for 10–14 days If patient can not tolerate oral intake, equivalent dose i.v. for up to 14 days Consider using inhaled corticosteroids by MDI or hand-held nebuliser Antibiotics (based on local bacteria resistance patterns) May be initiated in patients that have a change in their sputum characteristics# Choice should be based on local bacteria resistance patterns Amoxicillin/clavulanate Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) If Pseudomonas spp. and/or other Enterobactereaces spp. are suspected, consider combination therapy MDI: metered-dose inhaler
#: purulence and/or volume
- Table 12
Level III: treatment in patients requiring special or intensive care unit
Supplemental oxygen Ventilatory support Bronchodilators Short-acting β2‐agonist (salbutamol (albuterol)) and ipratropium MDI with spacer, two puffs every 2–4 h If the patient is on the ventilator, consider MDI administration Consider long-acting β‐agonist Corticosteroids If patient tolerates oral medications, prednisone 30–40 mg orally·day−1 for 10–14 days If patient cannot tolerate, give the equivalent dose i.v. for up to 14 days Consider using inhaled corticosteroids by MDI or hand-held nebuliser Antibiotics (based on local bacteria resistance patterns) Choice should be based on local bacteria resistance patterns Amoxicillin/clavulanate Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) If Pseudomonas spp. and/or other Enterobactereaces spp. are suspected, consider combination therapy MDI: metered-dose inhaler
Jump To
- Article
- Background
- Definition of COPD
- Diagnosis of COPD
- Epidemiology, risk factors and natural history of COPD
- Pathology and pathophysiology in COPD
- Clinical assessment, testing and differential diagnosis of COPD
- Smoking cessation
- Management of stable COPD: pharmacological therapy
- Management of stable COPD: long-term oxygen therapy
- Management of stable COPD: pulmonary rehabilitation
- Management of stable COPD: nutrition
- Management of stable COPD: surgery in and for COPD
- Management of stable COPD: sleep
- Management of stable COPD: air-travel
- Exacerbation of COPD: definition, evaluation and treatment
- Exacerbation of COPD: inpatient oxygen therapy
- Exacerbation of COPD: assisted ventilation
- Ethical and palliative care issues in COPD
- Integrated disease management for primary care in COPD
- Conclusions
- References
- Figures & Data
- Info & Metrics